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Ich habe 2002 in Denver die Operation des Lipodems und den Vorschlag zu ihrer Standardisierung vorgestellt. Heute konnen wir die Follow-up-Untersuchungen der Patienten besprechen. Alle Patienten wurden mittels indirekter Lymphszintigraphie und indirekter Lymphangiographie vor- und nachuntersucht. Die Ergebnisse zeigen eindeutig, dass die Liposuktion beim Lipodem zu einer Normalisierung des Lymphflusses fuhren. Die Schmerzhaftigkeit des Krankheitsbildes Lipohypertrophia dolorosa wird drastisch verbessert. Manuelle Lymphdrainage und Kompression, die bislang bei diesen Patientinnen an Armen und Beinen lebenslang durchgefuhrt werden mussten, werden in der Frequenz mindestens verringert. In den meisten Fallen konnte vollig darauf verzichtet werden. Ich werde eine Variation der Operation in Lagerung und Zugangsweg vorstellen. Wir operieren heute die Arme und Beine in insgesamt zwei Sitzungen. Der Stellenwert der postoperativen manuellen Lymphdrainage und der lang andauernden Kompression durch Garments soll im besonderen noch einmal unterstreichen, dass es sich bei der Operation des Lipodems nicht um eine ausschlieslich asthetische, sondern in erster Linie um eine medizinische Indikation handelt.

The disease "Lipedema", which has been known since 1940, is increasingly better understood. Dimpled edema in particular is not significant in women with fat distribution disorders on the arms and legs. These and other scientific findings are "work in progress" with the aim of renaming the disease. A "proper name" is "Lipohyperplasia dolorosa" (LiDo). With LiDo, the increase in volume is genetically fixed, but the pain is dynamically progressive. A LiDo must be distinguished from other symmetrical, painless fat distribution disorders on the arms and legs at first sight and after palpatory examination, especially from the occasionally coincident obesity. Obesity is never comorbid, but often coincident with LiDo. Although physical activity and a change in diet can reduce obesity, they cannot eliminate the disproportionate increase in fat tissue on the extremities that is exclusively caused by LiDo. In LiDo patients coincident with obesity, gastric surgery has no effect on the obligatory pain. There are both conservative and surgical treatment options for LiDo. A procedure that has been established since 1997 is surgical treatment using lymphological liposculpture. As part of this operation, large wounds are created under the skin, which, according to the "Rules of Nine" when treating both arms in one session and the suction of the legs in 2 sessions per operation, correspond to an area of ​​18% of the body surface. However, with adequate postoperative management and the administration of antibiotics and antithrombotics, local complications associated with the operation are rare. The most important result of consistent surgical treatment of lipohyperplasia dolorosa is the impact on quality of life: "It ruined her life" becomes "It improves her life".

Background  Untreated lymphedema of an extremity leads to an increase in volume. The therapy of this condition can be conservative or surgical. Methods  "Lymphological liposculpture" is a two-part procedure consisting of resection and conservative follow-up treatment to achieve curative volume adjustment of the extremities in secondary lymphedema. This treatment significantly reduces the need for complex decongestive therapy (CDT). From 2005 to 2020, 3,184 patients with secondary lymphedema after breast cancer and gynecological tumors were treated in our practice and clinic. "Lymphological liposculpture" was applied to 65 patients, and the data were recorded and evaluated by means of perometry and questionnaires. Results  The alignment of the sick to the healthy side was achieved in all patients. In 58.42% ( n  = 38), the CDT treatment could be completely stopped postoperatively; in another 33.82% ( n  = 22) of the patients, a permanent reduction of the CDT was achieved. In 7.69% ( n  = 5) patients, the postoperative CDT could not be reduced. A total of 92.30% ( n  = 60) of the patients described a lasting significant improvement in their quality of life. Conclusion  "Lymphological liposculpture" is a standardized curative sustainable procedure for secondary lymphedema for volume adjustment of the extremities and reduction of postoperative CDT with eminent improvement of the quality of life.

BackgroundThere are both conservative and surgical treatment options for Lipohyperplasia dolorosa (LiDo). A procedure that has been established since 1997 is the surgical treatment through Lymphological Liposculpture according to Cornely™.AimAfter extensive suctioning of the extremities, an extensive subcutaneous wound cavity with a trabecular connective tissue scaffold remains. Nevertheless, surgery-related complications are rare. Postoperative management and administration of antibiotics and antithrombotics are reviewed. The therapies for complications are presented in detail.Materials and methodsRetrospectively, the frequencies of adverse events in 1400 LiDo surgeries in 2020 were evaluated. The mean age of the patients was 47.81 years (range 16–78 years). Symmetrically, 504 outer legs (outer half of the limb [BO]), 504 inner legs (inner half of the limb [BI]), and 392 arms [A] were surgically treated.ResultsRelevant adverse events rarely occurred: infections (1.79%), seromas (0.79%), erysipelas (0.28%), necrosis (0.14%) and deep vein thrombosis (0.07).DiscussionWe were able to reduce the rate of postoperative complications to 3.07% in the Lymphological Liposculpture™ regime for the surgical treatment of LiDo. In their meta-analysis on liposuction, Kanapathy et al. reported an overall incidence of major surgical complications of 3.35%. The overall incidence of minor surgical complications was 11.62%, with seroma (5.51%) being the most common minor complication [26]. Kruppa et al. report that the liposuction procedure including fat removal for esthetic reasons has a complication rate of 9.5%. Wound infections with 4.5% and the formation of erysipelas with 4% are clearly in the foreground [20].

640 patients from a specialist clinic for operative lymphology were surveyed with the help by a questionnaire issued by the German Society of Pain Therapy (Deutsche Schmerzgesellschaft e. V.). This survey collected responses to questions about pain and pain characteristics as well as demographic data. It revealed that only a little more than 50 % of respondents were genuine cases of obesity. Lipoedema and obesity must therefore be regarded as clinical pictures unrelated to one another. The pain was mostly described as pressing and tearing in nature. Attributes such as throbbing or pulsing, consistent with acute inflammation, were rated as "not applicable". Symptoms were independent of the BMI, which is only useable to a limited extent in lipohyperplasia dolorosa. On the whole, the main symptom "pain" is multi-faceted. The study initiated by the German Federal Joint Committee (G-BA) must therefore be viewed critically. Congenital (as opposed to acquired) lipoedema fat on the extremities significantly impairs a person's ability to undertake activities in general as well as leisure activities. Since no objectively verifiable findings in lipoedema can be ascertained thus far, the diagnosis should be based on a careful patient survey.

<p>Bei 640 Patientinnen einer Fachklinik für operative Lymphologie erfolgte mittels Fragebogen der Deutschen Schmerzgesellschaft e. V. eine Befragung. Neben Fragen zum Schmerz und zur Schmerzcharakteristik wurden gleichzeitig noch demografische Daten miterhoben. Es ergab sich, dass nur bei etwas über 50 % eine echte Adipositas nachgewiesen werden konnte. Lipödem und Adipositas müssen als unabhängige Krankheitsbilder gewertet werden. Der Schmerz wurde überwiegend als drückend und ziehend empfunden. Attribute wie klopfend oder pochend, passend zu einer akuten Entzündung, erfuhren die Wertung „nicht zutreffend“. Die Beschwerdesymptomatik war unabhängig vom BMI, der bei der Lipohyperplasie dolorosa nur bedingt verwertbar ist. Insgesamt ist das Leitsymptom „Schmerz“ sehr facettenreich, das angeborene, nicht erworbene Lipödemfett der Extremitäten führt zu einer deutlichen Beeinträchtigung der Aktivitäten sowohl allgemein als auch im Freizeitbereich. Die durch den G-BA initiierte Studie muss daher kritisch gesehen werden. Da bislang keine objektivierbaren Befunde beim Lipödem erhoben werden können, ist eine subtile Befragung betroffener Patientinnen zur Diagnosestellung notwendig.</p>

Lipedema may be considered a model for healthy expandability of subcutaneous adipose tissue (SAT). This condition is characterized by the disproportional and symmetrical SAT accumulation in the lower-body parts and extremities, avoiding the abdominal area. There are no circulating biomarkers facilitating the diagnosis of lipedema. We tested the hypothesis that women living with lipedema present a distinct pattern of circulating parameters compared to age- and BMI-matched women. In 26 women (Age 48.3 ± 13.9 years, BMI 32.6 ± 5.8 kg/m2; lipedema group: n=13; control group: n=13), we assessed circulating parameters of glucose and lipid metabolism, inflammation, oxidative stress, sex hormones and a proteomics panel. We find that women with lipedema have better glucose metabolism regulation represented by lower HbA1c (5.55 ± 0.62%) compared to controls (6.73 ± 0.85%; p<0.001); and higher adiponectin levels (lipedema: 4.69 ± 1.99 mmol/l; control: 3.28 ± 1.00 mmol/l; p=0.038). Despite normal glycemic parameters, women with lipedema have significantly higher levels of total cholesterol (5.84 ± 0.70 mmol/L vs 4.55 ± 0.77 mmol/L in control; p<0.001), LDL-C (3.38 ± 0.68 mmol/L vs 2.38 ± 0.66 mmol/L in control; p=0.002), as well as higher circulating inflammation (top 6 based on p-values: TNFSF14, CASP8, EN-RAGE, EIF4EBP1, ADA, MCP-1) and oxidative stress markers (malondialdehyde, superoxide dismutase and catalase). Our findings suggest that the expected association between activation of inflammatory and oxidative stress pathways and impaired glucose metabolism are counterbalanced by protective factors in lipedema.

BACKGROUND: Lipedema often remains undiagnosed in patients with obesity, leading to mismanagement of treatment. Because of this, despite remarkable weight loss after bariatric surgery and decreases in hip and abdomen circumference, some patients show only small decreases in circumference of the extremities and report persistent limb pain. OBJECTIVE: The goal of this work is to raise awareness of lipedema coincident with obesity, mistakenly diagnosed as obesity alone, in order to ensure the correct diagnosis of the condition and to achieve better treatment outcomes for people with lipedema and coincident obesity. SETTING: CG Lympha Clinic, Cologne, and Ernst von Bergmann Clinic, Potsdam. METHODS: From clinical records, we identified 13 patients who were diagnosed with lipedema only after undergoing bariatric surgery. We describe the course of their pain before and after bariatric surgery, focusing on the long-term progression of symptoms accompanying the disease. RESULTS: Lipedema cannot be cured by bariatric surgery, and although the patients in this study lost an average of more than 50 kg of weight, they displayed no improvement in the pain symptoms typical of lipedema. CONCLUSIONS: Because of the different etiologies of lipedema and obesity, lipedema requires its own specific treatment. Patients suffering from obesity should always be assessed for pain and lipedema. If coincident lipedema is diagnosed, we suggest that bariatric surgery only be performed first if diet and exercise have failed, the patient's body mass index is >40 kg/m2, and the patient has been informed of the possible persistence of pain. Lipedema, like a coincident disease, must be additionally treated conservatively or preferably surgically. This optimized treatment may help to better manage patient expectations after weight loss.

Lipohyperplasia dolorosa (LiDo), also known as lipedema, is a painful subcutaneous adipose tissue disorder. While the characteristic bilateral accumulation of adipocytes in extremities sparing hands and feet is investigated, an objective characterization of pain and the sensory system of LiDo patients is missing. Accordingly, progress to overcome the unsatisfying response to pain-therapeutics of patients of this widespread, lifelong, and severe disease is missing. We characterized the sensory detection profile of painful and non-painful stimuli in 20 non-obese LiDo patients and 20 waist-to-height-ratio matched controls using the clinically approved QST-protocol of the German Research Association on Neuropathic Pain (DFNS e.V.). Further, pain-reports and participants’-psychometry was assessed using the German Pain Questionnaire. LiDo patients showed no overt psychometric abnormalities. LiDo pain appeared as somatic rather than neuropathic or psychosomatic aversive. All QST measurements were normal with the selective exception of two: The pressure pain threshold (PPT) was strongly reduced and the vibration detection threshold (VDT) was strongly increased selectively at the affected thigh. In contrast, sensory profiles at the dorsum of the hand were normal. ROC-analysis of the combination of PPT and VDT of thigh versus hand shows high sensitivity and specificity, categorizing correctly 96.5% of the measured participants as LiDo patients or healthy controls, respectively. Thus, we propose to assess both, PPT and VDT, at the painful thigh and the pain-free hand as basis to develop a combined PVTH-score for differential diagnosis as a fast and convenient bedside test for the identification of non-obese LiDo patients.

BACKGROUND: Lipedema, also known as lipohyperplasia dolorosa (LiDo), is a painful condition affecting women, causing a disproportionate accumulation of subcutaneous adipose tissue in the extremities. It carries a lower risk of diabetes and cardio-metabolic dysfunctions compared to obesity, but coincident obesity can complicate diagnosis and treatment. PATIENTS AND METHODS: This retrospective study included 607 female LiDo patients, ≥ 18 years, stage 1-3, from Germany, the UK, and Spain. Data were collected as part of the standard initial assessment for LiDo patients. RESULTS: Based on waist-to-height-ratio (WHtR), 15.2% of patients were underweight, 45.5% normal weight, 22.1% overweight and 17.3% obese. There was a significant association between WHtR category and age group. Body mass index (BMI) is often overestimated, leading to misdiagnosis of obesity. CONCLUSIONS: The use of BMI also affects the recent decision of the German Federal Joint Committee on the reimbursement of liposuction costs by health insurance funds. Patients with BMI of more than 40 kg/m2 are excluded from cost coverage, and those with BMI between 35 kg/m2 and 40 kg/m2 must first receive conservative obesity therapy. In conclusion, the sole use of BMI in lipedema is unreliable and, in contrast to WHtR, leads to inaccurate diagnoses overestimating overweight and obesity.

This S2k guideline was developed on the initiative and under the German Society of Phlebology and Lymphology (DGPL) leadership. The guideline aims to optimize the diagnosis and treatment of lipedema. It is intended to bring together the different approaches of the respective professional groups in a consensus-based manner and thus offer a basic concept for the best possible treatment of patients with lipedema. Sixty recommendations were formulated and agreed on in diagnostics, conservative and surgical treatment options, psychosocial factors and self-management. The guideline is intended to reflect the current scientific knowledge and be widely used for diagnosis and treatment recommendations for patients with lipedema. In particular, the guideline comments on diagnostic criteria, differential diagnoses, and coinciding clinical pictures, their influence on diagnosis and treatment, sensible treatment measures, and self-management options. The lipedema guideline summarizes the current national and international evidence and the German expert consensus and derives recommendations for the best treatment for patients with lipedema. The recommendations in the guideline are intended as an orientation aid in the sense of action and decision-making corridors from which deviations are possible in justified cases.

The present, revised guidelines on lipedema were developed under the auspices of and funded by the German Society of Phlebology (DGP). The recommendations are based on a systematic literature search and the consensus of eight medical societies and working groups. The guidelines contain recommendations with respect to diagnosis and management of lipedema. The diagnosis is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if - despite thorough conservative treatment - symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction.